Case summaries are a vital part of providing doctors (particularly for specialist medical examinations) with a good and specific idea of the claim's history. This also avoids the need of providing the doctor with file papers that may be irrelevant.
So, what does a case summary look like? Typically, it should be based on the sample outline on the next page:
|
Case Summary - Johnny Bloggs |
|
Background |
|
The background should provide clear details about how the condition occurred, including the date of injury. |
|
History |
|
A complete chronological history of the claim should be supplied, from the date of injury. While information should be kept concise (a case summary should not be more than 2 pages maximum), it is important to include incapacity and medical treatment details, where applicable. |
|
Current status |
|
The claim's current status should be clearly outlined. This will provide the doctor with an indication of why his or her opinion is now being sought. |
|
Medical and other evidence |
|
Any medical reports or other evidence should be listed in chronological order, briefly detailing the following: |
|
Date of evidence; who the evidence is from; what the evidence is. |
|
Example |
|
12/03/1996 Dr Jimmy Smith Medical report |
Any information listed as evidence in the case summary should be copied and provided to the doctor as part of the request for a medical report.
Provision of a case summary will give the doctor an opportunity to assess his or her own records and write a more constructive report than one which is simply based on the facts as presented by the employee.